Bulimia and anorexia nervosa: cutaneous manifestations

Bulimia and anorexia nervosa (BN, AN) are considered psychiatric disorders that have physical complications. Several factors may play a role in the onset of AN and BN, including a familial predisposition to these disorders, as well as individual personality characteristics. Dissatisfaction with body shape and an overwhelming desire to be thin are considered as risk factors for the development of eating disorders. Skin changes are characteristic and are cardinal diagnostic symptoms and pointers to the diagnosis of eating disorders. They are a consequence of starvation and/or malnutrition, self-induced vomiting, drug consumption and concomitant psychiatric illness. A careful examination of the skin can suggest a diagnosis of eating disorder. Cosmetic dermatologists, whose patients are mostly women, have a unique opportunity to detect these signs. This is very important as an early diagnosis will influence prognosis.     

Acrodermatitis enteropathica with anorexia nervosa

Acrodermatitis enteropathica is a rare hereditary or acquired disorder of hypozincemia. It is characterized by acral and periorificial dermatitis, alopecia, diarrhea and growth retardation. Anorexia nervosa is characterized by low body weight, body image distortion with an obsessive fear and is also associated with various cutaneous findings including acrodermatitis enteropathica. We report a 37‐year‐old female with acrodermatitis enteropathica showing acquired zinc deficiency with anorexia nervosa.     

Dissatisfaction with skin appearance among patients with eating disorders and non-clinical controls

BACKGROUND: We have recently observed that women with the eating disorders (EDs) anorexia nervosa and bulimia nervosa report a significantly greater (P = 0.002) dissatisfaction with the appearance of their skin than do non-clinical controls. OBJECTIVES: To examine further the nature of the dissatisfaction with skin appearance in women with EDs. METHODS: Several psychosocial and body image parameters, including whether or not the subjects were satisfied with a wide range of attributes associated with non-diseased skin, were surveyed in women aged < or = 30 years. Survey data from 32 women with EDs and 34 randomly selected community-based non-clinical controls were examined. RESULTS: Eighty-one per cent of the patients with EDs vs. 56% of the controls reported dissatisfaction with the appearance of their skin (P = 0.03), particularly with respect to its dryness and roughness. Other attributes that were rated more frequently were 'bags' and 'darkness' under the eyes, freckles, fine wrinkles and patchy hyperpigmentation. CONCLUSIONS: There is a high prevalence of dissatisfaction with skin appearance among women aged < or = 30 years, which is even higher among patients with EDs.     

Patients' perspective of pruritus in chronic plaque psoriasis: a questionnaire-based study

Background  Pruritus in psoriasis patients has not been regarded as a major symptom.
Objective  To study the pattern of pruritus in chronic plaque psoriasis.
Methods  A questionnaire was sent out to 109 patients with a diagnosis of chronic plaque psoriasis, who attended our outpatient departments during the period of January 2006 to January 2007.
Results  Out of 109 patients, 80 patients (74%) answered the questionnaire. Pruritus was found in 80% of the patients, with an intensity of 5.2 ± 2.6 (±SD) using a visual analogue scale (0–10). The frequency and intensity of pruritus were higher in women. Lower leg and scalp were reported to be the most commonly affected sites. Major aggravating factors for pruritus were stress and dryness of skin. Sun, sleep and vacation could relieve pruritus. The most common antipruritic treatments used by the patients were topical steroids, topical vitamin D, emollients and ultraviolet light therapy, whereas antihistamines were used by a small number of patients. Mood, concentration and sleep were negatively affected by pruritus.
Conclusion  Pruritus is a common symptom in patients with chronic plaque psoriasis.     

Scratching and noxious heat stimuli inhibit itch in humans: a psychophysical study

BACKGROUND: Patients who suffer from chronic itch employ creative techniques to alleviate their itch, often using painful thermal stimuli, such as hot and very cold showers, as well as mechanical stimuli, such as scratching. OBJECTIVES: The present study examined whether the sensory perception of itch is attenuated by remote interactions between both thermal and mechanical stimuli and afferent information related to itch. PATIENTS AND METHODS: Itch was induced with histamine iontophoresis in 21 healthy young subjects. Repetitive thermal stimuli including innocuous warmth, innocuous cool, noxious cold and noxious heat as well as scratching were applied 3-cm distal to the area of histamine iontophoresis. Subjects rated their perceived intensity of histamine-induced itch with a computerized visual analogue scale. RESULTS: Itch intensity ratings were significantly reduced during each period of scratching and repeated noxious heat and cold. Innocuous cooling and warming did not significantly alter itch intensity ratings. Inter-individual differences in histamine-induced itch sensitivity were unrelated to inter-individual differences in pain sensitivity. CONCLUSIONS: The present psychophysical study demonstrates that repetitive noxious thermal and scratching stimuli inhibit itch and do not require direct physical interaction with the area of the skin from which itch originates.     

Aquagenic pruritus: associated diseases and clinical pruritus characteristics

Background: Aquagenic pruritus (AP) can be induced by systemic diseases. The distribution of underlying diseases in a representative patient collective has not been investigated. This retrospective study aimed to determine the frequency and pruritus‐specific parameter of systemic diseases in a series of patients. Patients and methods: Data of 39 patients with AP (24 f, 15 m; mean age: f: 51.3 ± 20.1, m: 57.2 ± 15.0 years) were obtained and statistically evaluated as follows: demographic data, pruritus characteristics, underlying diseases, family history. Results: 30.8 % of patients exhibited polycythemia vera or myelofibrosis (Group 1: G1), in 69.2 % (G2) no underlying disease was found. 25.6 % had lactose intolerance as possible contributing factor. Women were significantly more common in G2 (p < 0.01), with a lower mean age (p < 0.01) and longer duration of AP (18.9 years, p < 0.01). Conclusions: AP occurs frequently with polycythemia vera. Other underlying diseases are rare; in over half of the patients no cause can be detected. In 25 % lactose intolerance is present which possibly acts as co‐factor. Demographic parameters (age, gender) allow estimation of the possible underlying disease in AP. Pruritus characteristics are similar in all groups and not helpful in determining the origin of AP.     

Efficacy of oral naltrexone on pruritus in atopic eczema: a double-blind, placebo-controlled study

Aim  The intent of our study was to determine the efficacy of oral naltrexone, an opiod antagonist, in the treatment of pruritus in patients with chronic eczema.
Methods  This double-blind, placebo-controlled study recruited 38 patients with eczema complaining from pruritus. Pruritus scores were evaluated. Patients were given placebo ( n  = 20) or naltrexone 50 mg ( n  = 18) for 2 weeks period. During the study, pruritus scores based on visual analogue scale system (VAS) were assessed three times: at the start of study, after 1 week, and after 2 weeks.
Results  In both groups, decreased VAS scores were observed, but naltrexone showed to be significantly more effective than placebo in decreasing VAS score after 1 week ( P <  0.005) and 2 weeks ( P <  0.001).
Conclusion  Naltrexone is more effective than placebo in the treatment of pruritus in patient with eczema. Naltrexone might be considered as an adjunct treatment in the treatment of pruritus. However, further studies in this aspect are highly fostered.

Conflicts of interest

This study and the authors were not supported by any company with a vested interest in the product being studied and the project was funded by Skin Research Center.     

Idiopathic aquagenic pruritus: pathogenesis and effective treatment with atenolol

Aquagenic pruritus (AP) is a rare condition with unknown pathogenesis. We explored its pathogenesis through investigations of a patient and report the first case to be effectively treated with atenolol. A 36‐year‐old Indian female presented with idiopathic AP. Small‐fiber neuropathy involving itch/pain‐transmitting C‐fibers appears to be pathogenetically important: compared with matched controls, our patient had increased intra‐epidermal nerve fibers, raised warmth detection threshold, and marked hyperknesis to electrical stimulation. Autonomic nerve function tests and fingertips vasoconstriction response were normal, indicating integrity of other small (Aδ and C) nerve fibers. She was initially treated with propranolol with good response, but was subsequently switched to atenolol for convenient once‐a‐day dosing. Symptoms were well controlled long term with no side effect experienced. Atenolol may exert its effect in AP through blockage of over‐activated neuronal sodium channels. Through the investigations, we propose that the pathogenesis of idiopathic AP may involve the following: upon contact of the skin with water, yet‐unknown mediator/s released stimulate dysfunctional and hyper‐innervated C‐nerve fibers, which may have resulted from a sodium channel defect. Atenolol may be a preferred therapeutic option compared with propanolol, in view of its convenient once‐a‐day dosing and better side effect profile.     

Effect of topical vitamin D on chronic kidney disease‐associated pruritus: An open‐label pilot study

Chronic kidney disease‐associated pruritus (CKD‐aP) is a troublesome symptom in patients with end‐stage renal disease (ESRD). Recently, vitamin D deficiency has been known to be one of the possible etiologic factors in CKD‐aP. However, limited data is available on whether topical vitamin D treatment is effective for relieving CKD‐aP. Therefore, the purpose of this study is to evaluate the effectiveness of topically vitamin D for CKD‐aP. Twenty‐three patients with CKD‐aP were enrolled in a single center, open‐label study. Patients were instructed to apply a topical vitamin D (calcipotriol) agent (Daivonex solution; LEO Pharma) or vehicle solution twice daily for a month. We assessed the efficacy and safety of topical vitamin D on CKD‐aP using clinical and dermoscopic photographs, and questionnaires including the validated modified pruritus assessment score (VMPAS) and visual analog scale (VAS) every 2 weeks. Dry dermoscopic findings showed significant improvement of scale (dryness) on the skin of topical vitamin D‐treated patients compared with those of the vehicle group. Both VMPAS and VAS were significantly decreased after 2 and 4 weeks of the topical vitamin D treatment compared with the vehicle, respectively (P < 0.05). No significant side‐effects were observed. Topical vitamin D may be one of the safe and effective therapeutic candidates for CKD‐aP.     

Itch Severity Scale: a self-report instrument for the measurement of pruritus severity

Background Assessing pruritus severity is difficult because of its subjective nature. A questionnaire that takes into account how the symptom is perceived by the patient may provide a more accurate representation of the pruritus. However, recently developed questionnaires do not specifically quantify severity of the symptom. Objectives To develop a self‐report questionnaire to measure pruritus severity and to provide initial evidence of its validity and reliability. Methods We modified a previously developed interview for the characterization and evaluation of pruritus, which was completed along with the RAND‐36 Health Status Inventory and Dermatology Life Quality Index by patients with psoriasis‐associated pruritus. Exploratory factor analysis, studies of internal consistency, and correlation analyses with health‐related quality of life scores were used to help determine which components of the modified pruritus interview to include in the new questionnaire, the Itch Severity Scale (ISS). The ISS was then assessed for construct validity, internal consistency reliability and test–retest reliability. Results Seven of the initial 11 components of the modified pruritus interview were included in the ISS. ISS scores correlated moderately with physical (r = −0·483) and mental (r = −0·492) health composite scores of the RAND‐36 and strongly with Dermatology Life Quality Index scores (r = 0·628), evidence of construct validity. It had an internal consistency reliability of 0·80 and a test–retest reliability of 0·95. Conclusions Based on this preliminary evidence of validity and reliability, this new seven‐item ISS may be useful in comparing pruritus severity among different disease populations or in assessing pruritus treatment effectiveness.     

An epidemiology study of patients with uremic pruritus

BACKGROUND: Pruritus is a common problem in continuous ambulatory peritoneal dialysis (CAPD) and haemodialysis patients. There are few studies on the clinical characteristics of uremic itch, the cause of which is still unknown. OBJECTIVES: The aim of this study was to define the prevalence and clinical characteristics of pruritus in CAPD and haemodialysis patients. METHODS: A questionnaire was used to evaluate pruritus in 52 CAPD and 289 haemodialysis patients in two dialysis units. The relationship of various factors and medical parameters to itch was examined. RESULTS: Of the 341 patients, 177 (51.9%) had pruritus at the time of examination, 97 (28.4%) had pruritus in the past. Pruritus was present in 145 (50.2%) of the haemodialysis patients and 32 (61.5%) of the CAPD patients. Men, patients with liver disease, and patients with pruritus before starting dialysis treatment were more likely to have uremic pruritus. CONCLUSIONS: This study showed us that uremic pruritus was observed more in men than women. The high prevalence of uremic pruritus in our study does not support the decrease of pruritus due to an improvement in the management of dialysis patients.     

表现为持续性瘙痒性斑块的成人Still病一例

患者,女,58岁。全身持续性瘙痒性斑块伴发热20天。血清铁蛋白增高,血常规白细胞、中性粒细胞升高,肝功能异常,脾大。皮损组织病理示：棘层中上部见角化不良细胞,真皮浅层血管周围见淋巴细胞和嗜酸粒细胞浸润。诊断：成人Still病。予糖皮质激素及甲氨蝶呤治疗,病情好转。     

Mast cell mediators other than histamine induce pruritus in atopic dermatitis patients: a dermal microdialysis study

While histamine is the crucial mediator of pruritus in type 1 allergic reactions, its role in atopic dermatitis (AD) is unclear. In this study, the role of mast cell mediators in protein extravasation and pruritus was evaluated using intradermal microdialysis. The microdialysis capillaries were used to apply the mast cell degranulating substance compound 48/80 (C48/80; 0.05%) or histamine (0.01%) and also to deliver H1-blockers (cetirizine, 200 microg mL-1) in nine AD patients and nine controls. Large pore size membranes (3000 kDa) enabled simultaneous analysis of protein extravasation. Itch sensation was measured psychophysically and weal and flare reaction were evaluated planimetrically. Protein extravasation induced by histamine and C48/80 was significantly reduced in AD patients. Blockade of H1-receptors by cetirizine significantly reduced C48/80-induced protein extravasation in AD patients and controls to an identical level. C48/80-induced pruritus was abolished by cetirizine in controls, whereas pruritus in AD patients was unchanged after H1 blockade. We conclude that mast cell mediators others than histamine are involved in C48/80-induced pruritus in AD patients. Whether the reduced capacity of AD patients to induce protein extravasation is of pathophysiological relevance for pruritus remains to be established.     

Matrix stimulation in chronic pruritus: A randomized controlled study

Chronic pruritus is one of the main symptoms in dermatology. We investigated a new intervention for chronic pruritus by neurostimulation through matrix electrodes. In this randomized controlled trial, 29 patients with chronic pruritus caused by a variety of dermatological diseases were allocated to an experimental group (EG; n = 14, 4-Hz neurostimulation of the itching area through matrix electrodes) or the control group (CG; n = 15, placement of matrix electrodes without neurostimulation). Outcome measures were the itching sensation as measured by a Numerical Rating Scale immediately after the intervention and the intermediate effect measured by the average itching sensation on the day before the intervention compared with the average itching sensation on day 1, 2 and 3 after the intervention. Regarding the short-term effect on itching, the anova showed a significant interaction effect for the 5-min stimulation with a larger reduction in the EG with a large effect size of d = 1.10. The average reduction in itching intensity was 78.2% for the EG compared with 34.3% for the CG. For the intermediate effect, no significant interaction was found (F = 1.721, P = 0.199). Comparing the itching sensation at day 0 with day 3, the interaction effect showed a statistical trend toward a greater reduction in the EG (F = 3.178, P = 0.086; statistical trend, d = 0.69). This study proved that neurostimulation through matrix electrodes is effective in the short-term reduction of itching in patients with chronic pruritus caused by dermatological diseases. Additional studies are needed with larger patient pools and covering longer study periods.     

Xerosis and pruritus in the elderly: recognition and management

Xerosis (dry skin) is characterized by pruritic, dry, cracked and fissured skin. Dry skin may be diagnosed as xerosis, eczema craquelé, dyshidrotic eczema, or asteatotic eczema. Two of the most common dermatologic problems found in nursing home residents are xerosis and pruitus. This article focuses on the recognition and treatment of these conditions, and stresses the importance of comprehensive treatment for these conditions as a preventative against stasis dermatitis and ulcer formation.     

Development of a psychological treatment service for pruritic skin conditions

The role of psychological contributions to common dermatological disease is increasingly recognized. It is often a challenge to find suitable psychological services to complement dermatological treatment. This paper describes the development of a psychological treatment service to reduce scratching behaviour found in common pruritic skin conditions. Our Department of Dermatology together with a consultation-liaison psychiatrist designed a four-session outpatient treatment programme incorporating psychiatric assessment, psychoeducation about the itch-scratch cycle, behavioural analysis, habit reversal techniques and between-session tasks for the patient to complete. This programme is actively modified in consultation with patients and their therapists to suit each patient's individual needs. Formal investigation is required to determine if this psychological treatment adds benefit in overall symptom control beyond dermatological treatment alone.     

尿毒症患者皮肤屏障功能改变及含青刺果油保湿霜治疗尿毒症瘙痒疗效观察

目的:探讨尿毒症瘙痒患者皮肤屏障功能改变及研究含青刺果油保湿霜对治疗尿毒症瘙痒的有效性及安全性。方法:分别测量60例尿毒症瘙痒患者(UP+组)、60例尿毒症无瘙痒的患者(UP-组)及30名健康人(HV组)胸前V形区、季肋区、前臂屈侧及小腿伸侧皮肤角质层含水量(SCH)、经皮失水率(TEWL)及酸碱度(p H)并分别进行问卷调查、干燥评分(XS)及尿毒症瘙痒评分(UIS)。随机将UP+组分为试验组及对照组,试验组予含青刺果油保湿霜治疗28d,对照组不给予干预。于D0、D28进行皮肤病生活质量评分(DLQI)。于D0、D7、D14及D28对受试者进行XS、UIS及SCH、TEWL及皮肤p H值测量。结果:UP+组及UP-组测SCH均显著低于健康人群(P<0.01)。UP+组胸前V形区、季肋区、小腿伸侧TEWL较健康人群显著升高(P<0.05)。UP+组胸前V形区及小腿伸侧皮肤p H值高于HV组(P<0.05)。尿毒症患者发生UP与TEWL呈正相关(P<0.001)。皮肤瘙痒程度与干燥程度呈正相关(P<0.001),糖尿病加重瘙痒程度(P=0.011)。试验组受...     

Management of chronic pruritus with a UV filtering topical cream

Chronic pruritus is a common dermatological condition affecting 10–13% of the general population. UVB phototherapy has been demonstrated to be effective in relieving the symptoms of pruritus. However, phototherapy is rarely administered because the treatment is time‐consuming and expensive, when compared to other topical drugs. In previous works, it has been reported that a topical cream, which selectively filters solar UVB can be used as a convenient alternative to traditional phototherapy. Here, we report the results of a pilot study aimed at assessing the effectiveness of the cream for treating pruritus. Seven patients with pruritus symptoms were included in the study. After 3 months of treatment (3 sessions per week), all patients noted improvement in pruritus symptoms. These preliminary results demonstrate that the novel topical cream could provide a convenient, low cost treatment for chronic pruritus patients.